Robert S. Remis

Comparisons of disparities and risks of HIV infection in black and other men who have sex with men in Canada, UK, and USA: a meta-analysis

BACKGROUND We did a meta-analysis to assess factors associated with disparities in HIV infection in black men who have sex with men (MSM) in Canada, the UK, and the USA. METHODS We searched Embase, Medline, Google Scholar, and online conference proceedings from Jan 1, 1981, to Dec 31, 2011, for racial comparative studies with quantitative outcomes associated with HIV risk or HIV infection. Key words and Medical Subject Headings (US National Library of Medicine) relevant to race were cross-referenced with citations pertinent to homosexuality in Canada, the UK, and the USA. Data were aggregated across studies for every outcome of interest to estimate overall effect sizes, which were converted into summary ORs for 106,148 black MSM relative to 581,577 other MSM. FINDINGS We analysed seven studies from Canada, 13 from the UK, and 174 from the USA. In every country, black MSM were as likely to engage similarly in serodiscordant unprotected sex as other MSM. Black MSM in Canada and the USA were less likely than other MSM to have a history of substance use (odds ratio, OR, 0·53, 95% CI 0·38-0·75, for Canada and 0·67, 0·50-0·92, for the USA). Black MSM in the UK (1·86, 1·58-2·18) and the USA (3·00, 2·06-4·40) were more likely to be HIV positive than were other MSM, but HIV-positive black MSM in each country were less likely (22% in the UK and 60% in the USA) to initiate combination antiretroviral therapy (cART) than other HIV-positive MSM. US HIV-positive black MSM were also less likely to have health insurance, have a high CD4 count, adhere to cART, or be virally suppressed than were other US HIV-positive MSM. Notably, despite a two-fold greater odds of having any structural barrier that increases HIV risk (eg, unemployment, low income, previous incarceration, or less education) compared with other US MSM, US black MSM were more likely to report any preventive behaviour against HIV infection (1·39, 1·23-1·57). For outcomes associated with HIV infection, disparities were greatest for US black MSM versus other MSM for structural barriers, sex partner demographics (eg, age, race), and HIV care outcomes, whereas disparities were least for sexual risk outcomes. INTERPRETATION Similar racial disparities in HIV and sexually transmitted infections and cART initiation are seen in MSM in the UK and the USA. Elimination of disparities in HIV infection in black MSM cannot be accomplished without addressing structural barriers or differences in HIV clinical care access and outcomes. FUNDING None.

Trends in HIV-1 in young adults in south India from 2000 to 2004: a prevalence study

BACKGROUND Major increases in HIV-1 prevalence in India have been predicted. Incident infections need to be tracked to understand the epidemics course, especially in some southern states of India where the epidemic is more advanced. To estimate incidence, we investigated the prevalence of HIV-1 in young people attending antenatal and sexually transmitted infection (STI) clinics in India. METHODS We analysed unlinked, anonymous HIV-1 prevalence data from 294 050 women attending 216 antenatal clinics and 58 790 men attending 132 STI clinics in 2000-04. Southern and northern states were analysed separately. FINDINGS The age-standardised HIV-1 prevalence in women aged 15-24 years in southern states fell from 1.7% to 1.1% in 2000-04 (relative reduction 35%; p(trend)<0.0001, yearly reduction 11%), but did not fall significantly in women aged 25-34 years. Reductions in women aged 15-24 years were seen in key demographic groups and were similar in sites tested continuously or in all sites. Prevalence in the north was about a fifth of that in the south, with no significant decreases (or increases) in 2000-04. Prevalence fell in men aged 20-29 years attending STI clinics in the south (p(trend)<0.0001), including those with ulcerative STIs (p(trend)=0.0008), but reductions were more modest in their northern counterparts. INTERPRETATION A reduction of more than a third in HIV-1 prevalence in 2000-04 in young women in south India seems realistic, and is not easily attributable to bias or to mortality. This fall is probably due to rising condom use by men and female sex workers in south India, and thus reduced transmission to wives. Expansion of peer-based condom and education programmes for sex workers remains a top priority to control HIV-1 in India.

Accuracy of serological assays for detection of recent infection with HIV and estimation of population incidence: a systematic review

We systematically reviewed the accuracy of serological tests for recent infections with HIV that have become widely used for measuring population patterns incidence of HIV. Across 13 different assays, sensitivity to detect recent infections ranged from 42-100% (median 89%). Specificity for detecting established infections was between 49.5% and 100% (median 86.8%) and was higher for infections of durations longer than 1 year (median 98%, range 31.5-100.0). For four different assays, comparisons were made between assay-derived population incidence estimates and a reference incidence estimate. The median percentage difference between the assay-derived incidence and reference incidence was 26.0%. Serological assays have reasonable sensitivity for the detection of recent infection with HIV, but are vulnerable to misclassifying established infections as recent-potentially leading to biases in incidence estimates. This conclusion is highly qualified by the apparent absence of a standardised approach to assay evaluation. There is an urgent need for an internationally agreed framework for evaluating and comparing these tests.

Lack of Evidence of Sexual Transmission of Hepatitis C Virus in a Prospective Cohort Study of Men Who Have Sex With Men

OBJECTIVES We studied the prevalence and incidence of hepatitis C virus (HCV) infection in the ongoing Omega Cohort Study of men who have sex with men (MSM). METHODS From January to September 2001, consenting men (n = 1085) attending a follow-up visit to the ongoing Omega Cohort Study were tested for HCV. If the test results were positive for HCV, we compared them with test results from previous serum samples collected from the time of entry into the original cohort study to determine the time of infection. RESULTS HCV prevalence at entry was 2.9% and was strongly associated with injection drug use (32.9% vs 0.3%, P<.0001). Only 1 seroconversion was identified in 2653 person-years of follow-up (incidence rate = 0.038 per 100 person-years). The seroconverter was an active injection drug user who reported needle sharing. CONCLUSIONS Sexual transmission of HCV among MSM appears to be rare.

Increases in HIV incidence among men who have sex with men undergoing repeat diagnostic HIV testing in Ontario, Canada.

ObjectiveTo estimate HIV incidence density for different exposure categories among people undergoing repeat testing in Ontario, Canada. MethodsPersons using voluntary, diagnostic HIV testing at least twice were identified by computerized and manual record linkage. In the 1992–2000 period, 980 seroconverters and 340 994 repeat negative testers contributed 936 145 person years (PY) of observation. Incidence density (ID) was calculated according to Kitayaporn et al.. Poisson regression was used to evaluate differences in incidence. ResultsAmong men who have sex with men (MSM), ID declined between 1992–1996, from 1.23 per 100 PY in 1992 to 0.79 per 100 PY in 1996 [relative risk (RR), 0.86 per year; 95% confidence interval (CI), 0.77–0.96]. Subsequently, ID increased to 1.39 per 100 PY in 1999 (RR, 1.18 per year; 95% CI, 1.05–1.34). In 2000, ID was 1.16 per 100 PY but this decrease was not statistically significantly different from 1999. MSM in their twenties had the highest ID in 1992–1996, but in 1996–2000 MSM in their thirties had the highest risk of infection. Among injecting drug users (IDU), ID decreased from 0.64 per 100 PY in 1992 to 0.14 per 100 PY in 2000 (RR, 0.87 per year; 95% CI, 0.80–0.94). Among heterosexuals, annual incidence remained constant at about 0.03 per 100 PY in 1992–2000. ConclusionsIncreases in ID were identified among MSM from 1996 to 1999. These findings are consistent with other research. Continued vigilance and improved surveillance are needed to better understand and control the epidemic.

The Impact of Infection on Population Health: Results of the Ontario Burden of Infectious Diseases Study

Background Evidence-based priority setting is increasingly important for rationally distributing scarce health resources and for guiding future health research. We sought to quantify the contribution of a wide range of infectious diseases to the overall infectious disease burden in a high-income setting. Methodology/Principal Findings We used health-adjusted life years (HALYs), a composite measure comprising premature mortality and reduced functioning due to disease, to estimate the burden of 51 infectious diseases and associated syndromes in Ontario using 2005–2007 data. Deaths were estimated from vital statistics data and disease incidence was estimated from reportable disease, healthcare utilization, and cancer registry data, supplemented by local modeling studies and national and international epidemiologic studies. The 51 infectious agents and associated syndromes accounted for 729 lost HALYs, 44.2 deaths, and 58,987 incident cases per 100,000 population annually. The most burdensome infectious agents were: hepatitis C virus, Streptococcus pneumoniae, Escherichia coli, human papillomavirus, hepatitis B virus, human immunodeficiency virus, Staphylococcus aureus, influenza virus, Clostridium difficile, and rhinovirus. The top five, ten, and 20 pathogens accounted for 46%, 67%, and 75% of the total infectious disease burden, respectively. Marked sex-specific differences in disease burden were observed for some pathogens. The main limitations of this study were the exclusion of certain infectious diseases due to data availability issues, not considering the impact of co-infections and co-morbidity, and the inability to assess the burden of milder infections that do not result in healthcare utilization. Conclusions/Significance Infectious diseases continue to cause a substantial health burden in high-income settings such as Ontario. Most of this burden is attributable to a relatively small number of infectious agents, for which many effective interventions have been previously identified. Therefore, these findings should be used to guide public health policy, planning, and research.

Willingness to participate and enroll in a phase 3 preventive HIV-1 vaccine trial.

Objectives: To assess the extent to which HIV‐negative cohort study participants would be willing to participate (WTP) in future HIV vaccine trials, to explore enrollment into an ongoing phase 3 HIV vaccine trial, and to assess changing WTP in such trials over time. Methods: The Vanguard Project is a prospective study of gay and bisexual men in the greater Vancouver region, British Columbia, Canada. Sociodemographic characteristics, sexual risk behavior, beliefs around HIV, and reasons for not participating in the AIDSVAX B/B trial were collected from self‐administered questionnaires. Contingency table analysis compared subjects who were WTP with subjects who were not WTP. Logistic regression analyses identified possible predictors of WTP. A subset analysis was conducted to assess changes in WTP in 2001 versus 1997. Results: Of 440 respondents, 214 (48.6%) were WTP, and 97 (22.0%) were not WTP. Those WTP were disadvantaged, sexually risky, and had a high‐perceived HIV risk (all p< .05). Reasons for not participating in the AIDSVAX B/B trial included fear of health problems and having missed the deadline for enrollment (all p < 0.05). Multivariate analysis revealed that having had a regular sex partner (adjusted odds ratio, 0.48 [confidence interval, 0.25‐0.92]) was a negative predictor whereas having a high‐perceived HIV risk (adjusted odds ratio, 5.35 [confidence interval, 1.57‐18.25]) was a positive predictor of WTP. Comparing WTP in 2001 with that in 1997, 24% of 100 participants who had been previously WTP were now not WTP. Conclusion: Improving community and participant knowledge about preventive HIV vaccine trials may help ensure informed consent. However, whether informing potential participants will reverse or contribute to the declining trend in WTP observed in this cohort warrants further investigation.

Experiences of and responses to HIV among African and Caribbean communities in Toronto, Canada

Abstract African and Caribbean communities in Canada and other developed countries are disproportionately affected by HIV/AIDS. This qualitative study of African and Caribbean communities in Toronto sought to understand HIV-related stigma, discrimination, denial and fear, and the effects of multiple intersecting factors that influence responses to the disease, prevention practices and access to treatment and support services. Semi-structured interviews were conducted with 30 HIV-positive men and women and focus groups were conducted with 74 men and women whose HIV status was negative or unknown. We identified a range of issues faced by African and Caribbean people that may increase the risk for HIV infection, create obstacles to testing and treatment and lead to isolation of HIV-positive people. Our findings suggest the need for greater sensitivity and knowledge on the part of healthcare providers; more culturally specific support services; community development; greater community awareness; and expanded efforts to tackle housing, poverty, racism and settlement issues.

Enough sterile syringes to prevent HIV transmission among injection drug users in Montreal

The HIV epidemic among injection drugs users in Montreal continues unabated. We wished to know whether sufficient syringes were being distributed to provide for the needs of injection drug users (IDUs) in Montreal. Using data from several sources, including the estimated number of active IDUs in 1994 and the injection frequency according to the drug consumed, we calculated the number of syringes required by IDUs. The number of syringes estimated was compared with the number of syringes distributed by needle exchange programs or sold in private pharmacies. Overall, we estimated that in 1994 about 10,683,000 syringes were required by the 10,000 IDUs in Montreal. Because about 338,000 syringes were distributed, <5% of the need was being met. The parameters in our analysis, particularly the number of IDUs in Montreal, drug use, and the frequency of injection, are subject to uncertainty. Nevertheless, because of the disparity between the small proportion of syringes distributed and the number required, it is unlikely that sufficient syringes are available to ensure access to clean needles and prevent HIV transmission. Measures should be taken to expand syringe distribution to Montreal IDUs.

Biological Factors that May Contribute to Regional and Racial Disparities in HIV Prevalence

Citation Kaul R, Cohen CR, Chege D, Yi TJ, Tharao W, McKinnon LR, Remis R, Anzala O, Kimani J. Biological factors that may contribute to regional and racial disparities in HIV prevalence. Am J Reprod Immunol 2011; 65: 317–324